There is no better illustration of the limitations of the
Serious Case Review as a tool of learning than the coverage of the recent case
of the fourteen-year-old girl who was forced by her mother to inseminate
herself.
For legal reasons, which are not explained, the name of the
local authority where these events took place cannot be divulged. That makes it
impossible for most professionals to access the report of the serious case
review or the executive summary. Instead we have to rely on the press coverage
which is, of necessity, somewhat abbreviated.
We are told that an unqualified member of children’s social
care staff was ‘fobbed-off’ when s/he tried to investigate concerns about the
mother’s care, but there are no details about exactly what happened or why.
In order to learn how to avoid mistakes and errors it is no
use having only sketchy, high level summaries of what went wrong. That’s like
saying that a plane has crashed because the pilots failed to keep it flying! We
need to know what has happened, we
need to know how it happened and we
need to know why it happened.
And the answers to such questions need to be available
nationally, not just to a small local elite.
We desperately need to re-examine the widespread assumption
that the Serious Case Review is an adequate tool of learning from mistakes. It
isn’t.
